Struggling to Breathe: Exploring Nurses’ Experience of Infant Feeding Support By
Joan Margaret Humphries BSN, University of Victoria, 2002
MN, University of Victoria, 2009
A Dissertation Submitted in Partial Fulfillment of the Requirements for the Degree of
DOCTOR OF PHILOSOPHY In the School of Nursing
© Joan Margaret Humphries, 2016 University of Victoria
All rights reserved. This dissertation may not be reproduced in whole or in part, by photocopy or other means, without the permission of the author
Supervisory Committee
Struggling to Breathe: Exploring Nurses’ Experience of Infant Feeding Support By
Joan Margaret Humphries BSN, University of Victoria, 2002
MN, University of Victoria, 2009
Supervisory Committee
Dr. Carol McDonald, (School of Nursing) Supervisor
Dr. Karen MacKinnon, (School of Nursing) Department Member
Dr. Annalee Lepp, (Department of Women’s Studies) Outside Member
Abstract
Supervisory Committee
Dr. Carol McDonald, Supervisor (School of Nursing)
Dr. Karen MacKinnon, Department Member (School of Nursing)
Dr. Annalee Lepp, Outside Member (Department of Women’s Studies)
The successful transition to motherhood can be associated with the experience of infant feeding, and women’s views of whether that experience has been positive or negative can shape the mothering experience. However, nurses’ engagement with best practice
breastfeeding promotion may elicit negative responses from women who are either unsuccessful in their attempts to breastfeed, or do not breastfeed for other reasons. Are nurses adequately prepared or supported to deal with the variety of infant feeding challenges that inevitably arise in perinatal practice settings? For example, Canadian perinatal nurses are expected to conform to WHO-conceived Baby Friendly expectations to disseminate evidence that pertains to the health risks of introducing formula to infants. However, in some circumstances, infant formula is recommended by practitioners in order to provide crucial hydration and/or nourishment, which destabilizes the discourse of risk, and creates confusion for mothers. Questions also arise about the appropriateness of nurses applying WHO guidelines to every woman without first considering intersectional realities which may not align with BF recommendations to breastfeed for six months and beyond. These questions, and others, informed the research question: “What is nurses’ experience of infant feeding support?” Eleven perinatal nurses from across Canada were interviewed. The conversations were interpreted using Gadamerian hermeneutic
methodology. Participants described a variety of practices and dilemmas that they associate with infant feeding “support,” highlighting that complex and contradictory forces are at play for nurses involved in infant feeding support as well as the unintended and negative consequences of following BF best practice guidelines.
Table of Contents Supervisory Committee………...p.ii Abstract………p. iii Table of Contents……….p. iv Acknowledgements………...p. v Dedication………p. vi Struggling to Breathe (Poem)………..p. vii Chapter One: The Enigma of the Deep………p. 1 Chapter Two: Accessing the Literature: Wading In ……….p. 23 Chapter Three: Hermeneutic Floating……….p. 64 Chapter Four: Taking the Plunge……….p. 106 Chapter Five: Coming Up for Air ………...p. 188 References………p. 250 Appendix I The Code………...p. 264 Appendix II The Ten Steps ……….p. 265 Appendix III Fraser Health Document………...p. 266 Appendix IV Intersectional Research………..p. 268 Appendix V Recruitment Document ……….p. 269 Appendix VI Historic Contributions………...p. 270
Acknowledgments
I would like to thank the institutions of Camosun College and the University of Victoria for the financial support and opportunities that were provided to me over the past many years. I would also like to thank the people associated with those institutions, for their moral support and encouragement.
I also want to sincerely thank my Committee, whose guidance and inspiration sustained me, and whose contributions mean so much to so many.
Dedication
For Carol, who is my messenger of wisdom and guidance. You have shown me how to tread water - and helped me to understand.
For my children, who are my messengers of inspiration and hope. You have given me the strength to surface in rough waters.
For Jake, who is my messenger of true partnership. You have swum alongside and kept me afloat.
Struggling to Breathe
How do I find myself here, treading water? What on earth caused me to leave The sand on the beach, and the view so enticing
Yet here I am, struggling to breathe
I wanted to feel how the seawater moved me. I wanted to see past the mist I wanted the freedom to kick, splash and practice
To be someone who could assist
The force of the undertow caught me as unaware- I must admit my surprise The current was strong and it took strength to surface
I doubt anyone hears my cries
I didn’t expect to be drawn to the underworld The allure of the deep still prevails
The insights I sought were concealed, then revealed, While resisting the urge to inhale
I’m OK-I’m keeping my head above water. I’m fine-I just need to stay calm I’ll try not to splash anyone who comes near me
I will not pull anyone down
That wave barely touched me, well OK, it shocked me (I tell myself that I don’t mind) I don’t think my gasp means I cannot tread water
I just need to sense what’s behind.
The view of the shore is becoming more distant. That shore looks so different from here… I wonder if anyone sees me from shoreline
Or whether I’ve now disappeared
I must have the courage to ask if I’ve faltered. I must question what I believed I maintain all trust that my senses will guide me to
Chapter 1: The Enigma of the Deep
It was a day like so many others, that day at the beach. We were happy to be together in friendship and comfort, enjoying the delights of the day. A wave of nostalgia
accompanies the memories of our laughter, the smell of the sunscreen, and the intimate sounds of gossip. Ah, and that glorious sound of the surge hitting the sandy beach. Boom,
boom, boom…the predictability and power of the tide is so alluring in my recollection. But I understand, now, that it was inevitable that I should leave the comfort of the beach. I recognize that it would be necessary for me to leave that pleasing place. How else could
I immerse myself and explore the enigma of the deep? The Origins of Departure
It is August 2014. Fraser Health Authority is featured in the news. The news story describes a document that women were asked to read and sign after giving birth, which indicated that they were aware of the health risks associated with formula (Appendix 3). This practice had been in place for seven years at Fraser Health Authority, but was only in August of 2014 that it came to the attention of the media by women who protested that the document was unethical and that it marginalized vulnerable women who were not breastfeeding. A blog was initiated. Women contributed their ideas to both “sides” of the debate - some defended the document and went on to cite sources such as the Cochrane Review1 as authoritative. Others were outraged that the document belittled mothers by featuring breastfeeding as the responsible choice in spite of evidence to the contrary.
1
“Cochrane Reviews are systematic reviews of primary research in human health care and health policy, and are internationally recognized as the highest standard in evidence-based health care.”
Sidney Harper RN (Project Development Nurse and Baby Friendly advocate for the Fraser Health Authority) responded to the public by contributing her own entries to the blog. She was clear that the intent behind the document was not to offend, but to reinforce the importance of breastfeeding promotion. She stated:
What I find most interesting is that our culture seems to be comfortable hearing about the benefits of breastfeeding but seems uncomfortable talking about the risks of artificial baby milks or formula. Research has shown that there are higher chances of colds, flu, ear infections, diarrhea and vomiting among other illnesses with formula use. It is easy to turn to formula when breastfeeding challenges present themselves. Mothers who deliver their babies in Fraser Health are offered support and encouragement to increase their confidence and meet their own breastfeeding goals whether in hospital or at home in their community. Breastfeeding is normal and for most babies any breastfeeding is good. If a woman is breastfeeding but is advised by a health care provider that formula is needed, formula is given as we would give a medicine – the right amount of formula for the right period of time can be very useful. (26/08/2014 3:51:09 PM) Dr. Christa Mullaly (MD FRCSC, Obstetrician-Gynecologist) criticized the document:
This is an appalling and unscientific document; I take issue with its content, language, and tone. For content, the highest quality evidence, from the randomized trials reported, clearly refutes your fuzzy points (‘may’, ‘might’, ‘could’). The only proven, validated information that you can provide to mothers is that a) formula-fed infants have a very small increase in risk of viral
gastrointestinal infection in the first year of life, and b) formula is really expensive. For language, vague terms like ‘might’, ‘may’, and ‘could’ are deliberately misleading and suggest greater validity than the science supports. Finally, the tone of this document is unnecessarily demeaning and cajoling. Its clear intention is to shame women who feed their children formula, even in cases in which formula is indicated and necessary for the infant's health. I strongly applaud your decision to pull the document and am highly skeptical that any incarnation of this form could respect women, their infants, and their feeding choices. (28/08/2014 6:13:44 PM)
Dr. Mullaly’s response exposes the conflict that surfaces in conversations about infant feeding approaches, wherein breastfeeding is pitted against formula feeding. Fraser Health ultimately pulled the document from circulation with apologies for offending women. Ms Harper stated that, “Infant feeding is an emotionally charged subject in our culture.” (Retrieved from: http://news.fraserhealth.ca/News/August-2014/The-choice-is-yours-supporting-moms-to-reach-their.aspx).
I introduce the news story as a way of introducing the intricacies of the hermeneutic interpretation that I undertook in this study in the process of addressing perinatal nurses’ experiences of infant feeding support. However, I was fascinated with infant feeding long before I read the news from Fraser Health. The news story, in many ways, was not news to me. My experience as a perinatal nurse over several decades had long given me pause, and I had often reflected on the enigmatic2 nature of the many
2 The word ‘enigmatic’ refers to that which is “mysterious,
puzzling, hard to understand,
mystifying, inexplicable, baffling, perplexing, bewildering, confusing”
approaches to and interpretations of opinions on literature pertaining to infant feeding support. I wanted to understand more about nurses’ participation. The hermeneutic study I undertook involved eleven Canadian perinatal nurses whose experience and interest in infant feeding support supplied the conversations for analysis.
The research conversations that transpired in the course of this study, as well as the academic preparation that I undertook leading up to the research, challenged many taken-for-granted discourses that underpin health promotion initiatives related to infant feeding in the perinatal period. Many elements converged to shape a unified address, in what Heidegger described as the “altogether” gasp of inquiry (Blattner, 2006). The question: “What is the experience of perinatal nurses who offer infant feeding support?” erupted from the dizzying array of discourses that pertain to infant feeding. My research must transcend a personal wish to work something out for myself, though, for as much as I hoped to achieve greater personal understanding by conducting research, I also aim to shape broader meaning. I ask what I can contribute to the larger disciplinary conversation, and what I can do to shape approaches to the phenomenon of infant feeding support (Moules, McCaffrey, Field, & Laing, 2014).
Canadian nursing practice is informed by the World Health Organization
(WHO)’s guidelines. In most Canadian maternity settings, nurses enact the authority of the Breastfeeding Committee for Canada (BCC) as the gold standard of best practice related to infant feeding support. I was curious to explore whether varied interpretations of these guidelines existed among my participants prior to starting the research, and how those variations shaped infant feeding approaches.
Other disciplinary perspectives, such as sociology, political science, and women’s studies, have also identified concerns about breastfeeding promotion as it is currently promoted worldwide. For example, Knaak (2006), Murphy (1999), Nathoo and Ostry (2010), Paterson, Scala, and Sokolon (2014), Wolf (2011) and others point to unintended negative consequences of breastfeeding promotion as outlined in the foundational World Health Organization (WHO, [2009]) guidelines. I am troubled that nurses’ experience of enacting globally-inspired guidelines remains largely unexplored in the nursing literature. The gap is significant, given the profile of nursing in the perinatal sphere. Women’s experience in the pre-natal, intra-natal, and post-natal realm most often includes nursing presence, and infant feeding support infiltrates each setting of perinatal nursing practice. According to Paterson, Scala, and Sokolon (2014), there have been policy debates in Canada on the categories of “maternal health,” “women’s health,” and “reproductive health.” I assume a certain distance and ask: “In what ways does the issue of infant feeding occupy a ‘position’ of health?” Does maternal emotional well-being and/or absence of guilt around infant feeding truly manifest a notion of health? The issue of guilt over infant feeding, as it pertains to government and public agendas, is not easily located in a health context. There is also debate over the role of rights-based frameworks and how service provision fits or does not fit. According to Paterson et al., reproductive rights are increasingly concerned with the many social influences that affect choices in the reproductive realm. However, there are political and public agendas at work that promote WHO-based ideologies surrounding breastfeeding promotion. These ideologies do not attend to specific social influences. Prior to engaging in this research, I was troubled by the lack of attention to individual exigencies in the Baby-Friendly literature and by
documents that permeate maternity settings which depict a “one size fits all” approach (Nathoo & Ostrey, 2010; Sokolon, 2014).
The word “enigmatic” entered my consciousness and promised to capture aspects of the multi-layered and hidden aspects of the topic of infant feeding support. It was shortly after I began to work with the word that I recalled hermeneutic philosopher Hans Georg Gadamer’s (1996a) work, The Enigma of Health. This coincidence produced a sense of serenity and conjured, once again, Jardine’s (2012) reference to “criss-crossing ideas.” I knew of Gadamer’s work, but I did not knowingly choose the word “enigmatic” in the context of Gadamer. Or did I? I proceed by accessing Gadamer’s speculations and the possibilities of situating my topic in the enigmatic context of health:
So what genuine possibilities stand before us when we are considering the question of health? Without doubt it is part of our nature as living beings that our conscious self-awareness remains largely in the background so that our enjoyment of good health is constantly concealed from us. Yet despite its hidden character health none the less manifests itself in a general feeling of well-being. It shows itself above all where such a feeling of well-being means we are open to new things, ready to embark on new enterprises and, forgetful of ourselves, scarcely notice the demands and strains which are put on us. This is what health is. (p. 112) I luxuriate in Gadamer’s depiction of health and contemplate the buoyant joy of a life that proceeds unthinkingly with living, being, and mothering.
Addressing the Address
How do I begin to explain the origins of inquiry, and my wish to explore an enigmatic area of nursing practice, which involves highly charged emotional investment
as well as controversy? By questioning breastfeeding promotion, as it is currently
understood and practiced, I may be perceived as debating the advantages of breastfeeding or undoing the good work of supporting mothers to breastfeed. I have encountered these critiques as I prepared to investigate.
Moules et al (2014) discuss Gadamer’s notion of “the address,” an idea that pertains to the position of one’s inquiry, which is neither the beginning nor the end of inquiry, but rather the place where one is “caught off guard” and “summoned” (p. 71). The occasion of my summons dwells in the heart of perinatal nursing. It is an enigmatic topic that involves many layers of engagement between mothers and nurses, and
paradoxical messaging which has the potential to damage women’s confidence and emotional well-being. Women’s suffering over infant feeding methods addressed me because I saw that, on the surface, the comfort of applying best-practice standardized approaches could guide nurses. However, the same approach also reveals a worrisome consequence for mothers who are unsuccessful at breastfeeding, or do not breastfeed for reasons that are hers to disclose, or not disclose, as she sees fit.
Over many years of nursing practice and graduate work, the “address” builds with relentless persistence. I stop and I listen. I seek meaning in the phenomena that surround the perinatal experience. I struggle to find my breath. Given that nurses are the
professionals who most often interact with mothers, I hope to shed light on an area of nursing practice that invites closer scrutiny. I wish to share my address with nurses and hope that my work will inform their care. Mostly, I imagine that by sharing the evolution of inquiry as it unfolded, I will be able to contribute to a multi-disciplinary call for diverse and particular approaches to infant feeding. This will disrupt current approaches.
My exploration promises discovery but, as is the case with all hermeneutic readings, the adventure invites your companionship. I bid you, the reader, to explore alongside with me, to question and interpret, and to participate in the understanding gleaned from nurses’ experience of infant feeding support. In our pursuit, there may be times when it feels as though we are swimming underwater and delighting in the discoveries, but also encountering the hidden menaces of the deep. There will be the temptation to seek the safe haven of the water’s surface, to re-orientate, and bask in the light. It may not be possible to find the surface easily, for unexpected waves of history and bias come from behind to confound our bliss. Those waves may catch us unaware, and we will once again need to interpret our surroundings and seek the horizon in order to understand where we are and locate ourselves once again. Our visions may change, depending on our situation in the swell.
Conditions of understanding. My interpretation aligns with the Lebenswelt, or “lifeworld,” so intrinsic to hermeneutic thought. Moules et al. (2014) suggest that “The lifeworld conveys the sense of the unthinking immersion in the world, in the way that we pass through a door without stopping to think about the door-ness of the door, its
mechanism, its history, or its symbolism” (p. 21). By attending to specific conditions of understanding, we become open to the nuances of larger conceptualizations of social, discursive, and historical approaches that Moules et al. explore, and which underpin nursing practice - and life - with unthinking persistence. The hermeneutic traditions in this work, therefore, assume the nuances of intersectionality and socially constructed notions of power and hegemony (including scientific privilege and feminism). Nursing scholars Van Herk, Smith, and Andrew (2010) address the advantages associated with an
intersectional theoretical perspective as it pertains to nursing practice, describing intersectionality as the process whereby categories of social identity intersect in the individual and result in differential experiences of privilege and oppression.
Foucauldian notions of discourse align the “discursive” hermeneutic nature of conversations with participants, and flourish within this hermeneutic condition of
understanding. Of particular note, Mills (1999) outlines Foucault’s notion that unintended consequences can be associated with embracing a particular discourse. According to Foucault, discourse is always socially constructed (Mills, 1999). Mills states: “Therefore, whilst political action can be accounted for theoretically within discourse theory, at the same time it is clear that one’s actions may have effects which do not match one’s intentions” (p. 27). The unintended consequences associated with current approaches to breastfeeding promotion permeate the inquiry.
The conversations that ensue in the research may disclose worrisome practice or attend to larger societal assumptions of science-based truth claims about breastfeeding. In conversation, things are left unsaid. Far from the metaphorical beach, my imaginings may take on a new dimension. Am I hearing the cries from the shore accurately? Unintended consequences of communication or lack of communication can be uncovered.
Scholarship, language, and dialogue propel understanding.
We will encounter the currents of history. The histories of nurses, mothers, my history, and your history escort the inquiry. The gendered nature of my conversations offered the possibility for unique streams of interchange between the participants and me. DeVault (1990) alluded to this possibility when she described the linguistic challenges
that can be associated with the nuances of dialogue between women engaged in the research interview. DeVault and Gross (2012) suggest that:
Another important idea is that how stories are told is not just an individual matter; people’s stories are shaped by the formats available to them and reflect the
perspectives and values of their communities. Thus, a narrative may be a place to see human agency in play with social structures, expressive activity that is shaped by its social context. (p. 219)
DeVault and Gross’s (2012) words expose the potential to consider unintended social consequences of breastfeeding promotion and the associated scientific health claims that shape breastfeeding promotion literature that nurses access. It would be important to consider what the language in the interview did not specifically reveal and how the “unsaid” operated in this context.
Other conditions may not yet be identified. These influences, and others, contour understanding in conscious and unconscious ways and offer hermeneutic visions of circling, spiraling, fused horizons - all of which contribute to understanding. There are circles of inquiry that include beginnings, insights, and doubts.
It is not my contention that the conversations with nurses represent a definitive story about perinatal nursing practice. Rather, the dialogue might invite ongoing wonder about the specific approaches that surface when nurses enact infant feeding support. When approaching that surface, you may engage with alternate understandings of the enigma of infant feeding support. Fortunately, there are infinite opportunities to take in the vision and catch our breaths. We can always tread water and contemplate the possibilities. I am moved by an image of practicing nurses who work under challenging
circumstances, doing all that they can to “stay afloat.” Aquatic metaphors abound and present themselves in what hermeneutic scholar David Jardine (2012) identifies as the unexpected, but persistent, “criss-crossing” of ideas: a coming towards something that is yet to be understood, but which beckons nonetheless.
It is unlikely that budding gills will resolve our adventure. Drowning is also improbable, for we have prepared ourselves well ahead of time. We embark on our immersion with trust and hope to sustain us. The time has come to swim underwater while seeking the light of the surface, to be hit by the wave, pulled down by the undertow. It is time to seek delight in the deep, and the process that leads to understanding.
The Turbulence: Coming to the Question The Context of Personal Experience
My social identities as a perinatal nurse, nurse educator, mother, and researcher in and of themselves do not sufficiently explain what led to inquiry. My own experiences of mothering, for example, were happy ones, but in spite of the straightforward and rewarding experiences that I personally enjoyed, like all mothers, I lived the challenges associated with giving birth and nurturing an infant. Over time, I wondered and worried about women I cared for in my nursing practice, many of who were struggling with multiple expectations, complicated social histories, and expectations to breastfeed.
Personal history shapes my inquiry. I worked as a perinatal nurse in a number of maternity settings in various locales. In that time, I encountered situations where there appeared to be division among nurses about enacting best practice guidelines, which are evidence-based and prescriptive. Some nurses embraced the guidelines wholeheartedly and others were skeptical. I recall the culture of my perinatal workplaces, wherein
evidence-based approaches were introduced and quickly asserted dominance. But quiet conversations among nurses, carefully orchestrated and enacted only in the presence of a safe chosen few, occasionally contested the direction of best-practice institutional
expectations to promote breastfeeding in accordance with prescriptive guidelines. The conversations remained as whispers, for to question the approach was to question the authority of scientific claims and universal truth. It seemed then, as it does now, that nurses struggled to articulate any concerns that defied the seduction of evidence-based approaches to a complex area of perinatal care. The dissimilarity in nurses’ approaches addressed me, for although there is much to be valued about promoting ideal practice, in this case divergent methods and attitudes among nurses emerged and affected care, strained relationships between nurses, and challenged institutional initiatives to promote breastfeeding according to best practice recommendations. The consequences are troubling. I have often been saddened by the realization that, for some women, birthing and caring for an infant can be a source of deep unhappiness and set the stage for a mothering experience that is fraught with insecurity and self-recrimination.
My work in the local perinatal mental health program exposed me to the suffering that women experienced when they did not, or could not, breastfeed. That setting
enhanced my understanding of perinatal mental health and also informed my advocacy for women’s overall emotional well-being in the perinatal period. At the clinic, the psychiatrist and clinical nurse specialist repeatedly shared that women who lived with mood disorders required undue amounts of reassurance that their infants could thrive - and lead healthy lives - without breastfeeding. My exposure to these circumstances were not exactly new to me, but it seemed as though the history of my perinatal nursing career
converged (almost with a sense of resignation) into the realization that this was an area that I had been called to investigate. The topic summoned me. I remember the sigh and the sense that perhaps my life experiences, my nursing experiences, and the nagging sense that something was wrong had prepared me for the inevitable. In his book The Power of Coincidence (2007, David Richo explores the experience of synchronicity:
This synchronicity can be just what it takes to spring us into changes and awakenings that we are ready to experience. Synchronous moments bid to us to pay attention to what comes now or next on our journey. From this point of view, awkward jolts can become graceful transitions, and stops can become steps. We grasp that the people, places, and events of our lives are showing us what we need to know or where we are ready to go. Everyone and everything in our story is part of how our life is coming together and there is nothing left to fear. We then stand at attention to our destiny and join it deliberately, rather than resisting,
complaining about, otherwise bemoaning our fate.
What I had noticed, sensed, and, finally confronted, drew me toward inquiry. I acknowledged the address.
Key Issues for Mothers
Bergum (1989) suggests that, “The woman is changed by the experience of bearing a child. She is not a mere vessel, but is an active, growing, changing participant” (p. 154). “Woman” becomes “mother” (1989). Bergum’s words depict the profundity of the birthing experience and shape inquiry by emphasizing the importance of successful transition into mothering.
The hermeneutic study (Humphries & McDonald, 2012) that followed my experience in the perinatal mental health program altered me deeply. None of the
participants of that study were breastfeeding at the time and they shared their deep shame. They related experiences of feeling judged, misunderstood, and even shunned by nurses when they abandoned breastfeeding. They worried about the consequences of the widely published risks of formula. It happened that, in most cases, my participants had been committed to breastfeeding, but for a number of reasons, these mothers were ultimately unable to breastfeed successfully. The following excerpt from that study reflects the poignancy:
Yeah, it was nothing positive even going in the direction of formula. You know they (public health nurses) don’t go anywhere near that, but some of the things that kept going through my mind were worrying me. And, you know, you try and keep going. You know-breastfed babies are more intelligent than formula fed babies, right? So I’m thinking ‘Oh my God’. I forget what the actual stat was, but they’re more intelligent. You know if you don’t breastfeed, then you’re just not giving the right start to your child. You know these things and you want to do that. And I didn’t even know if there were going to be learning disabilities and that kind of thing. (Humphries & McDonald, p. 383)
One of the most striking understandings that evolved from that study was the realization that it was the emotional turmoil leading up to the decision not to breastfeed that mothers found most tortuous. The study exposed mothers’ feelings of social isolation. Many women indicated that their intentions in becoming mothers and mothering were easily
misunderstood by nurses when breastfeeding challenges resulted in the decision to feed the infant formula.
The arrival of a new infant in a woman’s life is associated with the vision of seraphic maternal contentment, Madonna-like devotion, and the bliss of motherhood. However, societal assumptions fail to capture the complexity and despondency that may accompany the transition. Knaak (2006) elaborates: “In failing to openly discuss the complete range of experiences associated with breastfeeding, we risk propagating idealized motherhood myths - myths that fail to adequately embrace the often difficult and unpleasant work of infant feeding.” (p. 413). In these circumstances, the exquisite vulnerability of women during the perinatal period determines the departure from assumptions surrounding maternal bliss.
The ease with which a woman accommodates the triumphs and challenges of the early perinatal experience is contingent on the social identities that she brings to her birthing. Hankivsky, Reid, Cormier, Varcoe, Clark, Benoit and Brotman (2010)
emphasize that women’s health research seeks to advance women’s health by addressing the many influences, including socio-economic influences that affect women’s lives and health. For example, lower breastfeeding rates exist among mothers with lower income and education, teenage mothers, among Indigenous women, and in locales such as
Atlantic Canada, where these social conditions are reflected (Gauld, 2010; Knaak, 2006). Mothers’ social locations factor into the quest for understanding.
Key Issues for Nurses
Nurses, too, are influenced by their social identities. Nurses share a standard of professional preparation and enjoy employment opportunities. However, intersectional
vectors of age, experience, specialty education, and graduate education distinguish each nurse’s social location.
The specifics of the ideologies and guidelines that support nurses’ infant feeding approaches will be explored and re-visited at various points in this work, with the understanding that women’s health and well-being are inextricably linked with the topic of infant nutrition. Without question, nurses work with complex maternal social
situations. For example, there can be unexpected challenges associated with nurses’ interactions, such as disclosures of sexual abuse by mothers who are struggling to enact breastfeeding in a context of emotional crisis. Beck (2009) discussed the negative implications of breastfeeding promotion in the context of a history of sexual abuse. Her work offers a transformational alternative in that it emphasized the option for nurses to give women “permission” to give up breastfeeding in order to restore mental health.
Before engaging in the research conversations, I wondered what supports are in place so that nurses can appropriately engage with the complications of infant feeding. For example, when nurses encounter complex social circumstances, what provisions exist other than to promote exclusive breastfeeding practice? Gauld (2010), Knaak (2007), and Sokolon (2014), too, wondered if the impetus to promote breastfeeding supersedes
attention to the intersectional elements of mothers’ social situations.
What else is at play among nurses when a mother lacks the capacity or the will to continue attempts to breastfeed? I was drawn to examine what may be at play among nurses who play such an important role in infant feeding support, including the context of women’s decision making. I wondered how practitioners view formula and what
or indeed as an alternative to breastfeeding. I continue to heed to the call of some mothers’ emotional responses to breastfeeding promotion. I am enveloped with the layers of
complexity that become associated with infant feeding approaches.
Waves of discomfort about current practice wash over me with relentless
persistence. They account for assumptions that I held, and continue to hold, about nurses and their interaction with mothers. For example, among nurses with whom I have
practiced, I most often recall a passionate and abiding respect for women’s experiences in the perinatal period. With that passion, there can be flashes of inspiration between nurses as well as clashes of understanding. Prior to conducting research, I wondered to what extent my assumptions would be either confirmed or challenged in the interview process. Mothers and Nurses’ Intersection
Infant feeding support can involve tears, triumph, and disappointment, and it is an area of nursing practice where mothers’ and nurses’ goals have the potential to become enmeshed. Bergum (2007) asks: “What does it mean to be a health care professional in the midst of women’s transformative experiences?” (p. 15). The unique histories and social identities of each mother and each nurse ideally collude at the juncture of birthing. Indeed, various social factors that influence the lives and emotional well-being of both mothers and nurses serve as ubiquitous companions in this inquiry. The intersectional lens therefore informs understanding of both mothers and nurses.
The Fraser Health document lurks as an emblematic nudge to my address. Sydney Harper spoke of supporting women’s goals, but I wonder how it came to be that nurses considered that they were supporting women’s goals in vulnerable post-partum moments, by asking them to sign a document that lists the health risks associated with formula. I
strive to understand and find meaning in the differing perspectives that inform nurses’ approach and mothers’ responses to nursing practice, including the complex conditions of understanding, including history, social identities, and pervasive societal discourses. For example, in circumstances when infant formula is recommended by practitioners in order to provide crucial hydration and nourishment, the discourse surrounding the risk of formula becomes destabilized. How do nurses navigate the inconsistent messages associated with evidence, informed choice, risk, and interdisciplinary influences that are associated with best practice? To what extent are relationships between nurses and mothers compromised in the context of the inconsistencies? The waves of inquiry gain momentum.
Pervasive Currents
Currents, currency, current thought, water currents. We are cast into a whirlpool of currents. Whirlpools and eddies suggest the circularity associated with hermeneutic thought. There are current (as in “up-to-date”) ideas to consider, and there is the currency of science. There are discursive currents to navigate. All of these associations with the word take their place in the interpretation and aid in understanding. Historical political and social initiatives, my history, my biases, the history and biases of the participants, the dialogue that occurs between us, and the “in the moment” insights and truths come together in conjecture and interpretation.
I think of myself as a good swimmer and recall the many experiences I have had in the water. I was taught how to swim and I taught others. I understand the principles of buoyancy. Surely that knowledge will sustain me in my predicament - or perhaps I need
to access other experiences and knowledge to survive. I am wondering if, and hoping that, you will swim alongside me.
We encounter the undercurrents of the unexpected, which will pull us in unplanned directions. We may wonder if our peers at the beach miss us or judge us for our folly. Among our peers, we realize there are various levels of comfort in the water. These understandings shape meanings associated with our dilemma. The differences and similarities among us affect us in profound ways. Although the undercurrents of the unexpected will catch us unawares and drag us to the depths, we endeavour to surface once again and find breath. There is discomfort associated with what we explore. The possibilities for interpretation are endless.
Charting the Course of Inquiry
Having offered a broad overview of my study, I outline the remaining signposts of the hermeneutic research process, which unfolds in five main sections.
In Chapter Two, I present a literature review and refer to the works that provide discursive underpinnings of my conceptualizations. I draw on the works of French philosopher Michel Foucault (1926-1984) and his ideas about discourse, including the unintended consequences associated with current approaches to breastfeeding promotion. I feature feminist authors who have engaged with the topics of breastfeeding and infant feeding. I also include the perspectives of political science and anthropology and examine the consequences of global breastfeeding promotional initiatives.
The progression of my literary inquiry was not linear. One element fed the other until my inquiry was contoured. As such, I describe the forces that shaped inquiry, knowing all the while that understanding does not evolve entirely by “listing”
components of the literature. Rather the totality of inquiry evolved, took shape, and was realized in a multi-dimensional fashion.
Chapter Three addresses the hermeneutic methodology that underpins my
approach to this inquiry. I examine the origins of Gadamerian hermeneutics by accessing the works of hermeneutic philosopher Hans Georg Gadamer (1900-2002) with reference to Gadamer’s Heideggarian roots, for Gadamer was a student of the Marten Heidegger (1889-1976). It is through the conduit of Heidegger’s works that Gadamer was able to articulate the tenets of philosophical hermeneutics. In doing so, Gadamer charted a possible course for research.
Notwithstanding the academic attention that I give to hermeneutics, it is the
unfettered resonance of hermeneutic thought that pervades my attention to the “everyday.” The moments of “Ah-ha! This is indeed what is going on here!” propelled me. It is
possible to live hermeneutics in metaphor, poetry, literature, and other interpretative ventures that dwell in discursive spaces of understanding. In this work, I do not wish to say: “Now I am displaying hermeneutic thought” as much as I hope to convey
hermeneutics with discretion and, perhaps, with the deftness of the trickster, Hermes, the Greek god after whom hermeneutics was named. In this way, I am challenged to separate hermeneutics as a distinct conversation. Indeed, hermeneutic thought pervades the
inquiry in its entirety, starting with the approach and residing in the interpretations. But in Chapter Three, I offer the foundational possibilities.
The theoretical approach of intersectionality moves alongside my hermeneutic explorations and I expose possibilities for intersectionality to inform understanding. The
presence of intersectionality, like hermeneutics, is embedded throughout the work, but named and articulated in Chapter Three.
Chapter Four presents, for me, the highpoint of my research. The preparation and planning that I undertook culminated, at last, in the conversations with perinatal nurses. The texts therein are rich and provocative. They invite repeated conjecture and demand attention to the discursive, social, and historical conditions of understanding that envelop the conversations. The excerpts that I chose from conversations are the passages that moved me, gave me pause, and challenged my assumptions. The passages stand alone and invite consideration in a milieu of contradiction and questions. They extend the hermeneutic address.
Chapter Five is the view toward the now distant shore. The origins of inquiry have been enacted. The chapter expresses the meaning that arises following my encounters with participants. I trace my personal response to the research, including unexpected insights. The chapter offers a way to navigate towards the shore with renewed insight and enhanced understanding. It features chosen excerpts from the research
conversations as well as personal wonderings. The participants’ contributions pepper my interpretations and my analysis of the possibilities for enhanced practice. The promise for further speculation, as always, remains.
The profound meanings attached to infant feeding, as it applies to feelings of successful mothering, serves as the beacon. The Fraser Health document, and women’s responses to it, shifted the tides and exposed, for a brief moment, what may lurk in the deep. Infant feeding support is indeed an enigmatic aspect of nursing practice. I engage with the enigma.
Who has fathomed the enigma of the deep? That obscure world where fearful darkness broods? Who has tamed the restless waves that never sleep?
So constant yet so changing in their moods? Who can know the secrets of the shifting seas
Where certainty is toppled by the tide Where confidence is humbled like an upturned tree
And blind confusion is the only guide?
(Taken from “Ocean World” Words by Anne Conlon
Chapter 2: Accessing the Literature and Wading In
Tentatively, I step into the surf. The water is cold, and the voices from the beach either urge me forward or taunt me. Shall I continue, or should I return to the comfort of the
shore?
I am pulled to what exists beyond the haze-and I prepare myself for the currents and undercurrents that lie beneath the surface. I shudder at the thought of immersing myself,
although I know immersion is inevitable. I anticipate the breathlessness of discovery. In Chapter Two, I explore important ideas, literature, and ideologies that have informed my inquiry. I reference the literature, which has, in part, shaped preliminary understandings and prepared me, as the researcher, to interpret the research conversations. I approach the literature by framing it in the context of theoretical and discursive
potentials to inform understanding. I share ongoing and emerging questions that arise from the literature and emphasize the dearth of nurses’ contributions to date. The possibilities to understand what is at play among nurses are buoyed by interdisciplinary perspectives. Indeed, exposure to interdisciplinary analysis uncovers the need to
investigate nurses’ perspectives about a practice that shapes perinatal nursing care. The literature sets the stage for the research.
Discursive Considerations
Foucault explicates discourse as a reflection of truth that is socially constructed, rather than transcendentally conceived (Mills, 1997). As such, Foucault implies that discourse does not represent what is “real.” Rather, discourse reflects the mechanics of how society arrives at a dominant discourse, and it was that process that captured Foucault’s interest. A Foucauldian view of power is closely associated and posits that
power is “dispersed through social relations” (Mills, 1997, p. 17) as opposed to representing power that is exerted in some way. In this work, I attend to Mills’
conception of Foucauldian discourse as discursive narratives, or “currents,” underpinning approaches to infant feeding support.
Discourse, then, surfaces in hermeneutic research dialogue (the “discursive utterances” of conversation [Mills, 1997]) as well as in the commonly held social
understandings. Discourses of medical science and evidence-based practice, for example, imply an adherence to scientific method, statistical analysis, and universal approaches to truth. Contrasting discourses may be founded in socially constructed or temporal
understandings of truth. Each aspect of discourse, including the discursive nuances that emerge in conversation and other taken-for-granted societal contexts, shaped the conditions of understanding that guided interpretation in this study.
Like hermeneutics, engaging with Foucauldian discourse theory has the potential to expose the unspoken, hidden aspects of human existence (Linge, 2008; Mills, 1997). I explore discourses that uncover webs of complex and contradictory forces that are at play in infant feeding support. Importantly, many of these forces have the potential to
empower as well as marginalize, and silence nurses and mothers during the important perinatal period (Beck, 2009; Humphries & McDonald, 2012; Murphy, 1999;
Shakespeare, Blake & Garcia, 2004; Wolf, 2011). The many discourses that are attached to the topic of breastfeeding expose various dilemmas.
Foucauldian Terminology
It is salient to explain the terms that Foucault used to describe discursive activity. According to Mills, Foucault envisioned a “discourse” as comprising a number of less
comprehensive discourses, which when seen in combination with each other create a cohesive narrative. Every day “utterances” or statements that lead to recognizable discourses, in turn, shape the broader discourse. Groups of discourses make up the “episteme,” which constitute the knowledge that is associated with a given discourse (albeit a temporal conception of knowledge) and which are subject to “epistemic breaks” when new knowledge replaces previous knowledge.
In describing Foucault’s “discourse theory,” it is not my intent to apply Foucault’s “discourse analysis” method. That is, I am interested in exploring discourses according to their meaning, rather than relegating them to Foucault’s definitive discursive structures. Foucauldian understandings, in my work, attend to the “pervasive, complex, and
frequently conflicting nature of power relations” (Williams, Kurz, Summers, & Crabb, 2012, p. 343) and open possibilities to understand the discursive influences that surround nurses’ practice.
The socially constructed nature of discourse and the inherent risk for unintended consequences offers a vantage point from which to proceed. Nurses’ practice realities are shaped by societal discourses of scientific privilege, which health care providers may openly acknowledge, as was depicted in the debacle surrounding the Fraser Health
document. Some discourses, however, may be relegated to a more marginalized influence. As Williams et al. (2012) summarize:
Hence, notions and images of the breastfeeding mother become interpretable not as neutral depictions of reality, but rather as social constructions that are shaped by relations of power that naturalize these images and ideas across a range of settings. (p. 343)
For each discursive possibility, hegemony, power, and exclusion can be assumed. Importantly, some discourses may assume the mantle of “common sense” and fortify their influence. I invite you, the reader, to consider the underlying discourses that shape the literature I describe, starting with the Baby Friendly Hospital Initiative.
Baby Friendly Hospital Initiative Political and Historical Origins
In the Western world, breastfeeding practice is seen as the preferred method for infant feeding, and currently assumes an uncontested status among health care providers and policy makers (Martin & Redshaw, 2011).
The history of breastfeeding promotion reflects a shift towards exclusive
breastfeeding practice, articulated by the joint WHO/ UNICEF’s Innocenti Declaration of 1991, wherein infant nutrition was enshrined as a basic human right (Nathoo & Ostry, 2009; Palmer, 2009). Importantly, that document featured breastfeeding as needing protection, promotion, and support (Retrieved from:
http://www.infactcanada.ca/innocenti_declaration.htm). The return to breastfeeding promotion in Canada led to the creation of the Breastfeeding Committee for Canada
(BCC), the “National Authority for the WHO/UNICEF Baby-Friendly ™ Initiative (BFI).” (Retrieved from http://www.breastfeedingcanada.ca/TheBCC.aspx). The following
description positions the Baby Friendly Hospital Initiative (BFHI) in the context of Canadian practice:
The BCC identified the WHO/UNICEF Baby-Friendly™ Hospital Initiative (BFHI) as a primary strategy for the protection, promotion and support of
must identify a BFHI Authority to facilitate the assessment and monitoring of the progress of the BFHI within its borders. The Breastfeeding Committee for Canada is identified as the National Authority for the Baby-Friendly™ Initiative (BFI) in Canada which it is working to implement through provincial and territorial action. (Retrieved from: http://breastfeedingcanada.ca/aboutus.aspx)
The protection of breastfeeding practice is a notion that pervades the perinatal nursing world. As a result of the widespread acceptance of Baby Friendly Hospital Initiative (BFHI) guidelines for infant feeding that originate with WHO, women throughout the world are exposed to breastfeeding promotional initiatives. The Baby Friendly documents that I discuss below, therefore, are merely a small portion of the publications that originate from WHO and Breastfeeding Committee for Canada (BCC) many of which are widely distributed in hospital and community maternity settings, and shape nursing practice.
Overview of Baby Friendly Hospital Initiative
I examine the WHO/UNICEF (2009)3 Baby Friendly Hospital Initiative (Retrieved from http://www.unicef.org/nutirionion/index_24850.html). There are five topics covered in the BFHI (2009).4 All but the last category is published online. The last section, entitled “External assessment and re-assessment” contains confidential
information about facility evaluation, and is not available unless requested by the national authorities that conduct evaluation of BFHI activity (WHO, 2009a).
I introduce the BFHI document as follows:
3
In the interests of brevity, and because UNICEF is an organization that is officially incorporated into WHO, I hereafter refer to WHO/UNICEF as WHO in the text of this work.
4
The Baby-friendly Hospital Initiative (BFHI) is a global effort launched by WHO and UNICEF to implement practices that protect, promote and support breastfeeding. It was launched in 1991 in response to the Innocenti
Declaration. The global BFHI materials have been revised, updated and expanded for integrated care. The materials reflect new research and experience, reinforce the International Code of Marketing of Breast-milk Substitutes, support mothers who are not breastfeeding, provide modules on HIV and infant feeding and mother-friendly care, and give more guidance for monitoring and reassessment (WHO, 2009a, p. 72).
The 1991 Innocenti Declaration, therefore, continues to serve as the foundational impetus for enacting the BFHI.
Section One: Background and Implementation
The introductory section of the BFHI document reinforces several foundational approaches found in previous publications and features some additions. However, the general thrust of breastfeeding advocacy remains unchanged. An overarching theme focuses on what steps health authorities must take to achieve “Baby Friendly” status - something that has proven difficult, given the prescriptive nature of the guidelines and the diversity of maternity conditions around the globe. That said, over 20,000 hospitals in 156 countries have been designated as Baby-Friendly since 1991, and the number is steadily growing (WHO, 2009a). BFHI has a presence in Canadian and United States (US) hospitals. The guidelines are seen as principles to guide practice and ostensibly to offer a reference point to which health care providers can be held professionally accountable.
The WHO (2009) BFHI revision makes it clear that the intent is to extend BFHI ideology to as many countries in the world as possible in both the First and Third Worlds.
The “Code of Marketing of Breastmilk Substitutes” (known as the “Code”) is a well-known component of the original BFHI (Appendix 1) and has been included in the 2009 BFHI revision. The meaning of the Code is summarized as follows: “One of the main principles of the Code is that health care facilities should not be used for the
purpose of promoting breast milk substitutes, feeding bottles or teats” (WHO, 2009, p.49). In compliance with the Code, health care facilities may not give out free formula, may not have formula visible, and may not have any visual representations of anything other than a breastfeeding mother in art or information that is posted. Information about how to safely feed an infant with formula is hidden and distributed only when an “informed choice” is made by the mother to feed the infant with formula. Whether or not the issue of safe preparation is at stake, the Code sends a clear message to women in hospital. The images of breastfeeding only and no visual exposure to formula or artificial nipples tells women that formula is not associated with best practice. For example, nurses are instructed as follows:
No displays of bottles in ward areas, visible stores or returns area - watch for windowsills that are visible from outside, and bottles stacked in wards. When parents see these products displayed in the hospital they think the hospital supports their use. While the health facility realizes these products are needed at times, it does not want to be seen as endorsing particular brands. (p. 20)
Another foundational feature of the 2009 BFHI is the global criteria for “Ten Steps for Successful Breastfeeding” (Appendix 11), which is the suggested basis for a
hospital’s approach to breastfeeding advocacy. An alternative “Ten Steps for Successful Breastfeeding” has also been designed to accommodate settings where there is a high incidence of maternal HIV/AIDS. In that document, considerable emphasis is placed on maintaining confidentiality about the mother’s status. There are also a number of
statements that suggest that the notion of informed choice underpins infant feeding in the context of HIV/AIDS. If a mother chooses not to breastfeed, it is important to honor the principles of “AFASS,” meaning that formula can only be considered if it is acceptable, feasible, affordable, sustainable, and safe. The history of WHO’s response to HIV/AIDS, however, is steeped in controversy. (Appendix V1)
Informed consent, as an ideology and a practicality, has implications that are far reaching in the context of HIV/AIDS as well as other circumstances. It is impossible to analyze the implications of the Ten Steps or the Code without considering the rhetoric of informed choice that underpins BFHI literature. According to BCC (2010):
A written curriculum for prenatal education used by the hospital and/or the community health service and written information for prenatal clients (such as booklets, leaflets, handbooks and text books with general information on pregnancy, parenting, infant feeding and child care) provide accurate, evidence based information. They are free of information on the feeding of human milk substitutes. Women who have made an informed decision not to breastfeed receive written materials on the feeding of human milk substitutes that is current, appropriate and separate from breastfeeding information. All written information is free of promotional material for products or companies that fall within the scope of the WHO Code.
(Retrieved from: http://www.swndha.nshealth.ca/BCC10integratedsteps.pdf) One of the headings in WHO Section One (2009a) addresses situations in which, according to BFHI imperatives, formula feeding is acceptable, citing some specific and rare health concerns that may apply to the mother and/or infant.
The 2009 version of the BFHI document includes references to being “mother-friendly.” The comment refers to supporting women who feed with formula, citing a desire to support the mother/baby dyad in the context of all infant feeding. For example:
This revised version of the assessment includes specific questions related to the training staff has received on providing support for ‘non-breastfeeding mothers’ and what actual support these mothers have received. The inclusion of these questions does NOT mean that the BFHI is promoting formula feeding but, rather, that the Initiative wants to help insure that ALL mothers, regardless of feeding method, get the feeding support they need. (p. 24)
Section Two: Strengthening and Sustaining the Baby Friendly Hospital Initiative: A Course for Decision Makers
A course was designed for decision makers in health authorities globally in order to facilitate progress in breastfeeding promotion (WHO, 2009b). The document reads:
Once higher level administrators and policy-makers have been sensitized to the importance of breastfeeding support in health facilities and the changes necessary to attain it, they will be more likely to encourage and support the continuing education needs of mid-level health workers. (p. 1)
The course outline suggests that the course is generally offered in a ten to twelve hour format. The references include attention to breastfeeding success rates, the advantages of
breastfeeding/disadvantages of “artificial” feeding, the scientific basis of the “Ten Steps to Successful Breastfeeding.” The context of HIV/AIDS is emphasized. The Baby Friendly way of being is also associated with cost savings.
Section Three: Breastfeeding Promotion and Support in a Baby Friendly Hospital This section of the document (WHO, 2009c) outlines a course for health care workers who will be providing direct care to women. The course is designed to be approximately eighteen hours long and emphasizes the following key assumptions:
Breastfeeding is important for mother and baby. Most mothers and babies can breastfeed.
Mothers and babies who are not breastfeeding need extra care to be healthy. Hospital practices can help (or hinder) baby and mother friendly practices. Implementing the Baby-friendly Hospital Initiative helps good practices to
happen (WHO, 2009c, p.1)
This section also addresses the many risks that are associated with “not”
breastfeeding. Role playing examples are meant to provide nurses with expressions and responses that are considered optimal.
The following excerpt captures the tone of the coaching:
How would you reply to a colleague who says, ‘You make mothers feel bad if you tell them that there are dangers if they do not breastfeed’? Health workers do not hesitate to tell women that there is a risk if they smoke during pregnancy or if do not have a trained person at the birth or if they leave their infant in the house alone. There are many risks to a baby that we tell women to try to avoid. Women have a right to
know what is best for baby and may feel angry if you withhold information from them. (Retrieved from: http://www.ncbi.nlm.nih.gov/books/NBK153456/)
Supposedly, by employing principles of informed choice, women will make decisions that are best for themselves and their infants, including the possibility of feeding an infant with formula, if the principles of AFASS are in place.
Section Four: Hospital Self-appraisal and Monitoring
The final section (WHO, 2009d) offers tools to determine whether facilities are ready to be evaluated as a Baby Friendly designated facility. Other facilities who do not work towards the designation, but who value Baby Friendly principles and values have access to the “Gold Standard” of maternity care. Briefly stated, this section reviews the many underpinnings of Baby Friendly care, including adherence to the Code, The Ten Steps, Mother-Friendly activities, acceptable reasons for breast milk substitutes, and other foundational tenets. A series of questionnaires are available to test knowledge about breastfeeding advocacy and mother-friendly environments.
The above discussion offered a brief overview of the BFHI (2009) document with the intention of providing a basic understanding of what is meant when we speak of BF guidelines. Knowledge of BF ideologies, as exemplified in the BFHI, is important because they shape both public health policy and public opinion. Much of the literature on this topic, as reviewed below, builds on these principles of breastfeeding promotion.
Mothers Feminist Discourse
Mills (1997) addresses Foucault’s relationship to feminist thought and acknowledges that Foucault’s work did not directly address gender issues. It seems,
however, that Foucault’s attention to power generated an interest among feminist scholars. According to Mills, feminist theorists see power in a gendered context, through which “vectors” (p. 71) of race and class appear, aligning with intersectional approaches. Mills emphasizes the utility of incorporating Foucault’s perspectives on power into feminist theoretical frameworks, inviting yet another dimension of understanding having to do with infant feeding discourse. The feminist scholarship that I access indeed reflects a web of power dynamics that pervade infant feeding and mothering discourses.
Feminists hold notions about motherhood. DiQuinzio (1999a; 1999b) contends that the term “motherhood” is impossible to conceive, since the word suggests a static and predictable state, as opposed to fluid and diverse mothering situations. On the one hand, DiQuinzio posits that some feminists consider mothering to be oppressive,
undermining women’s autonomy. On the other hand, some feminists see mothering as an important manifestation of female identity and an impetus for women’s political activism. According to DiQuinzio (1999a) “the issue of motherhood often functions as a sort of lightening rod” (p. xi), wherein the many issues that women face become attached to mothering. Therefore, feminist approaches must address mothering, since decisions about when, if, and how mothering occurs is an important issue in all women’s lives
(DiQuinzio, 1999a; DiQunizio, 1999b).
Apple (1999) traces the evolution of “scientific” motherhood that evolved in the US during the nineteenth and twentieth centuries. She comments on the influences of various educational structures (both formal and informal), cultural icons, and the media -all in the context of shifting “idealizations of motherhood” (p. 90). Apple states that
“Scientific motherhood is the insistence that women require expert scientific and medical advice to raise their children healthfully” (p. 90).
Apple’s (1999) account points to a number of disturbing trends. For example, as a result of the increased dependence on medical expertise, it seems that, over the past fifty years, women were placed in the impossible position of being both responsible and not responsible for their children. Women were increasingly encouraged to educate
themselves at the feet of the “experts” (such as Dr. Spock and the family physician), but were denied ultimate autonomy over decision-making. For example, strategies that had previously been associated with the learned art of mothering, passed down through women through the generations, were suddenly undermined by burgeoning scientific knowledge. The underlying message throughout this transition remained the same: that it was through motherhood that women were able to discover fulfillment and establish their identity. Interestingly, these ideals coincided with an increased scientification of domestic life in general, wherein increased technology in the home, expectations about scientific approaches to cooking, and other developments served to professionalize homemaking. At the same time, motherhood was being professionalized. Advice from neighbors was no longer considered a viable option for solving problems about child care - a higher scientific authority (usually the physician) was considered to be the expert (Apple, 1997). Apple (1997) concludes that, “The image of the scientific mother changed from the queen of the nursery to the servant of science” (p. 105).
During the time period covered in Apple’s analysis, the reverence for science in the context of infant feeding swung from a reliance on medical advice that advocated formula feeding, to a reliance on medical advice that advocated for breastfeeding. There
is irony that, in both cases, medical advice is privileged in spite of the obvious contradictions between the standpoints.
Risk. Feminist scholar Joan Wolf’s (2011) work, Is Breast Best? Taking on the Breastfeeding Experts and the New High Stakes of Motherhood, constitutes a significant current contribution to the discussion about unintended consequences of breastfeeding promotion. Wolf addresses many issues that had been largely ignored in the literature at the time of her writing. In the context of my interests, Wolf explores such relevant topics as the concept of “total motherhood,” wherein women come to believe that they are responsible for eliminating all risks to their children.
Wolf (2011) posits that we live in a world that is shaped by an ideology of “total motherhood” (p. 71). She says:
Total motherhood stipulates that mothers’ primary occupation is to predict and prevent all the less-than-optimal social, emotional, cognitive, and physical outcomes: that mothers are responsible for anticipating and eradicating every imaginable risk to their children, regardless of the degree or severity of the risk or what the trade-offs might be; and that any potential diminution in harm to
children trumps all other considerations in risk analysis as long as mothers can achieve the reduction. (p. 71-72)
According to Wolf (2011), the goal of attaining total motherhood is synonymous with breastfeeding.
Wolf also engages in an analysis of breastfeeding promotion. Wolf systematically critiques foundational empiric studies that underpin the science of breast milk superiority. Her analysis is at odds with the myriad of literature that features breast milk as a
substance that prevents infant health issues (Brenner & Beusher, 2011; Groer & Davis, 2006; Mohrbacher & Kendall-Tackett, 2010; WHO, 2009). An evaluation of Wolf’s critique of these foundational studies is beyond the scope of this study, but her work aligns with hermeneutic perspectives on the temporality of scientific evidence. For example, a recurring theme of philosophical hermeneutics questions the prominence, authority, and legitimacy of scientific methods as a way of establishing universal truth. The hermeneutic approach does not privilege science as the definitive understanding of the human experience (Gadamer, 1998; Paley, 1998), but instead includes science, as well as other questions, that are important to human life.
It is worth noting, though, that in spite of the multi-disciplinary approach Wolf (2011) undertook in her work, she did not include nurses as contributors. Her omission confirmed my desire to contribute to the literature by centering a nursing perspective.
Wolf specifically takes aim at American initiatives, such as the National Breastfeeding Awareness Campaign (NABC), and offers a critique of its advertising campaign. Advertisements that were launched between 2002 and 2006 included posters, pamphlets, and billboards and capitalized on the public’s confusion about the meaning of risk. In one advertisement, a rubber nipple was placed on a bottle of insulin, suggesting that formula causes diabetes. Another advertisement displayed a pregnant woman on a mechanical bull. The caption read “You’d never take risks when you’re pregnant. Why start now?” (Cited in Wolf, 2011, p. 109), suggesting that feeding an infant with formula is tantamount to riding a bull when pregnant. The implications of these depictions are huge. What is the experience of mothers when children become ill or are born disabled, or premature, or die? Are mothers responsible for contravening all risks?
